States struggle with Affordable Care Act

HARTFORD, Conn. -- Facing tight deadlines and daunting workloads, states across the country are scaling back ambitions for implementing the Affordable Care Act.

At a monthly board meeting of Connecticut's health insurance exchange, members of the standing-room-only crowd got a reminder that they, too, were behind schedule. The insurance marketplace they were working on nights and weekends won't be completely ready on time.

That's why Connecticut -- like other states across the country -- has lowered the bar, doing what it can in the time it has left before the health-care law's major programs are launched Oct. 1.

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Although the states are promising to provide new marketplaces for individuals to compare and buy health insurance plans, the Web portals will be a bare-bones version of what was initially envisioned.

And then there are the federal setbacks. The Obama administration has put off significant aspects of the health-care overhaul as it races to finish provisions that will give Americans more insurance options and provide many with financial assistance to buy coverage. On Tuesday, the White House announced a decision to delay the "employer mandate," a requirement that employers with 50 or more workers provide coverage.

"In 2011, there was this 'we're going to save the world' mentality," said Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. "In 2013, it focuses more on how do we deliver on the requirements of the law."

The District of Columbia and 15 states -- including Connecticut -- are building their own marketplaces. Those jurisdictions, among the Affordable Care Act's most ardent supporters, took on the responsibility of building Web portals that are at the heart of the federal health-care overhaul. Most states, eschewing the heavy workload, left the task to the federal government.

The White House expects 7 million people to buy health insurance or enroll in Medicaid through these Web portals. Millions more are likely to browse these sites for health plans and explore possible options under the federal law, which imposes an "individual mandate" requiring most people to obtain coverage or pay a penalty.

In Connecticut, Counihan and his colleagues decided in January to delay about 30 percent of the Web portal functions they had hoped to have ready by October.

"We were beginning to slip in timing," Counihan said. "We were getting these messages that we weren't going to be able to hit our timelines because of the complexity. Some things were either requiring more time or coding than we had expected."

When a consumer asks to be exempted from the individual mandate, for instance, the request will probably have to handled manually, by an exchange worker, rather than automatically, by a computer. Technology to track those points at which customers give up on the application process -- turning away from the website rather than completing the application -- will also wait until a later date.

"This is a two- to three-year implementation we're doing in 10 months," Counihan said. "I wish we had one more year."

Across the country, other states report similar problems.

In Oregon, officials decided to delay a feature that would allow consumers to customize searches for rating the coverage provided by insurers. And a feature for insurance brokers to track the consumers they enroll will wait for two to four months.

How will brokers keep track of potentially thousands of customers in the interim? Cover Oregon's executive director, Rocky King, suggested that they might use "index cards."

"I know the agents will have all their Excel worksheets," King said. "We've gone to them and said: 'You're our priority sales force, but you're not necessarily the priority for how you access the system. The consumers are.' "

"The longer the process takes, the more difficult it is," said Jon Hager, executive director of Nevada's Silver State Health Insurance Exchange. "It will affect our enrollment, so we are trying to make sure we have those items implemented as soon as possible."

Hager described the Web chat function as a "low-impact item" because users with questions will be able to reach out to a call center, which will be ready by Oct. 1. "The things we delay are those that we think will not have a significant impact," he said.

The federal government has faced multiple delays on health-care provisions affecting employers. The White House's announcement Tuesday that it would not enforce the employer mandate until 2015 followed a setback in April, when the administration decided to delay for a year a key function of the small-business marketplace. Rather than allowing each employee to pick a health plan, as the law intends, workers will have to enroll in a plan selected by their employers.

The Government Accountability Office recently questioned the federal government's ability to launch the federal exchange, which will serve the majority of states next year.

"Whether [the administration's] contingency planning will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined," the GAO said.

For states that are setting up their own exchanges, the administration will make sure that they are ready in October, said Alicia Hartinger, a spokeswoman for the Center for Medicare and Medicaid Services.

"Americans in every state will be able to shop for quality, affordable insurance in a marketplace beginning October 1, 2013," she said in a statement. "We have provided states with the flexibility they need to build a marketplace that meets their needs, and we are working closely with them to ensure that they are ready."

Even after deferring some items, Connecticut officials still say they face long nights and weekends in the office to get the new marketplace off the ground on schedule.

At Access Health CT, employees regularly turn up during nonbusiness hours. The office is closed Friday, the day after the Fourth of July holiday, as a way to force employees to take a day off.

"At 9 p.m., you would have no trouble finding someone to go out to dinner with," said Peter Van Loon, the exchange's chief operations officer, about a typical day. "Come in at noon on Saturday and you could hold a meeting. It's not that people are chained to their desk. I have trouble kicking people out."

Connecticut has made progress. It was the first state to complete an intensive technology test in which the state's portal successfully connected to a federal data hub.

But officials have learned that good news can have a downside. The state agency spent weeks reprogramming its website after the federal government shrank the insurance application from 21 pages to three.

When the Supreme Court struck down a key element of the federal Defense of Marriage Act, Access Health CT board members cheered. Then, they remembered that it would add to the workload: The marketplace would now need to recognize same-sex marriages, a coding change unlikely to be ready for October.

"Everything continues to change all the time," Van Loon told his staff at a meeting later that day. "We're going to have to adjust some processes around that. If DOMA requires a manual work-around, we'll do that."